Jornal Internacional de Saúde Mental de Emergência e Resiliência Humana

Abstrato

A Study on the Quality of Medical Records in Hadiya Zone Southern Ethiopia

Martha Gebreyohannis Selamu*, Liranso G. Selamu

Medical record is initial point of patient data production and primary source for all health information related to patient care, health service quality, decision making and resource allocation. However, the quality of medical records (MRs) is rarely evaluated and quality dimensions of medical record are not well assessed particularly in the study area as well as in Ethiopia. The study was intended to assess the quality of medical record in public health centers of Soro district, Hadiya Zone, Southern Ethiopia. Facility based cross- sectional study design supplemented with qualitative inquiry was conducted among randomly selected four health centers (HCs) in Soro district, Hadiya zone. Data on the quality of medical records were collected by reviewing document using checklist, while qualitative data for triangulation were obtained by interviewing key informants from the health center and to describe possible reasons for poor medical record quality. The data were entered in to Epidata version 3.1, exported, and analyzed by SPSS version 22.0. A total of 384 medical records were reviewed from one-year medical records of four public health centers with 98% retrieval rate. Among the dimensions of MRs quality, none of health centers had enough facility for medical record quality and no auditing of medical record document as of the standard. Majority of medical records had incomplete administrative, clinical and legal components as of health centers standard of the country. The studied HCs are not fulfilled the national medical record management requirements to run medical record system of health centers since the Ethiopian HCs standard set the medical record personnel to be a health information technician and a minimum of three in numbers. Thus, medical record service providers should be trained and necessary supplies should be equipped in all health center.